Interventions for reducing self-stigma in people with mental illnesses: a systematic review of randomized controlled trials

Background: Self-stigma occurs when people with mental illnesses internalize negative stereotypes and prejudices about their condition. It can reduce help-seeking behaviour and treatment adherence. The effectiveness of interventions aimed at reducing self-stigma in people with mental illness is systematically reviewed. Results are discussed in the context of a logic model of the broader social context of mental illness stigma. Methods: Medline, Embase, PsycINFO, ERIC, and CENTRAL were searched for randomized controlled trials in November 2013. Studies were assessed with the Cochrane risk of bias tool. Results: Five trials were eligible for inclusion, four of which provided data for statistical analyses. Four studies had a high risk of bias. The quality of evidence was very low for each set of interventions and outcomes. The interventions studied included various group based anti-stigma interventions and an anti-stigma booklet. The intensity and fidelity of most interventions was high. Two studies were considered to be sufficiently homogeneous to be pooled for the outcome self-stigma. The meta-analysis did not find a statistically significant effect (SMD [95% CI] at 3 months: –0.26 [–0.64, 0.12], I2=0%, n=108). None of the individual studies found sustainable effects on other outcomes, including recovery, help-seeking behaviour and self-stigma. Conclusions: The effectiveness of interventions against self-stigma is uncertain. Previous studies lacked statistical power, used questionable outcome measures and had a high risk of bias. Future studies should be based on robust methods and consider practical implications regarding intervention development (relevance, implementability, and placement in routine services).


Sample search strategy
A sample search strategy for Medline via Ovid: 1 mental health/ 2 exp mental disorders/ 3 mentally ill persons/ 4 ((mental* or psychiatr* or psychological* or developmental* or learning or substance*) adj (ill* or disorder* or disease* or distress* or disab* or problem* or health* or well-being or wellbeing or patient* or treatment or retardation)).tw. 5 ((chronic* or severe* or serious* or persistent) adj (mental* or psychiatr* or psychological*)).tw. 6 (emotional adj3 (disorder* or problem*)).tw. 7 (((psychos#s or psychotic* or schizo* or depression or depressive or bipolar or mania or manic or obsessi* or panic or phobic or phobia or anorexi* or bulimi* or borderline or narcissis* or personality) adj1 disorder) or self injur* or self harm or substance abuse).tw. 8 1 or 2 or 3 or 4 or 5 or 6 or 7 9 stereotyping/ 10 social distance/ 11 self-stigma.mp. 12 (internali* or perceive* or personal or experienc* Low risk Not stated in publication. Additional information provided by author: "The randomization sequence was generated by an online random number generator."

Allocation concealment
High risk "After completion of the interview, the interviewer opened a sealed envelope to identify which type of information the client was randomly assigned to receive and delivered the appropriate information." According to additional information provided by the author the envelopes were opaque and placed in the recruitments and interview packets, which were sequentially numbered. However, the envelopes themselves were not sequentially numbered.

Blinding of participants and personnel
High risk Blinding of participants and those delivering the treatment was not possible due to the nature of the intervention.

Blinding of outcomes assessment
High risk "Interviews and information sessions were conducted by two interviewers, one who was Black and one who was White. The interviewers alternated baseline and follow-up interviews for each client, so that clients would not be asked to provide their perceptions about the psychoeducation to the same interviewer who delivered it." Rationale for judgement: Outcomes were assessed by the same person delivering the intervention.

Incomplete outcome data
High risk "Thirty-four of the 42 clients (81%) completed follow-up interviews (19 Psychoeducation,15 General Information). Of the eight not interviewed, 4 (50%) were contacted but could not be scheduled during the follow-up window, 3 (38%) were not successfully located, and 1 (13%) refused." Rationale for judgement: Data were missing from more than 10% of the participants. Data may not be missing completely at random, since it cannot be excluded that reasons for missing data are both unrelated to observable and unobservable variables. Thus, the available case analysis is likely to be biased. No imputation or sensitivity analysis were performed.

Selective reporting
Unclear risk This was impossible to judge due to unavailability of a study protocol.
Other biases Low risk One of the scales was modified by the authors, which may influence validity. However, this outcomes was not relevant to the systematic review. No other potential biases were apparent. Allocation concealment Unclear risk The method of concealment was not described in either of the two associated references and contacting authors was unsuccessful.

Blinding of participants and personnel
High risk Blinding of participants and those delivering the treatment was not possible due to the nature of the intervention.

Blinding of outcomes assessment
Low risk "The CSSMIS, CAQ-SPMI, SUMD and CGSS were completed by experienced research assistants via face-to-face interview with the participants. The raters were not informed the treatment assignment of the participants."

Incomplete outcome data
Low risk "The missing data was computed by the principle of Last Observation Carried Forward." "The attrition rates for the experimental and comparison groups were 0% and 6.25% respectively." Rationale for judgement: LOCF may not have been appropriate because from the tables it appears that means were not stable across time and differential attrition rates suggests that data may not have been missing completely at random. However, data were missing from less than 15% of participants and differential attrition was less than 10%, rendering the risk of bias likely to be low (see section on incomplete outcome data for further explanations).

Selective reporting
Low risk No study protocol was available, but the same outcomes were reported in the both study reports (PhD thesis and journal publication).

Other biases Low risk
No other apparent biases were detected.

Random sequence generation
Low risk "Participants were allocated to groups by randomly pulling group assignment." Rationale for judgement: Procedure is based on drawing lots principle and thus appears appropriate.

Allocation concealment
Unclear risk "Participants were allocated to groups by randomly pulling group assignment (group vs. control) from an envelope." Rationale for judgement: The characteristics of the envelopes were not reported, so the appropriateness of the method of allocation could not be judged. Contacting the author was unsuccessful.

Blinding of participants and personnel
High risk Blinding of participants and those delivering the treatment was not possible due to the nature of the intervention.

Blinding of outcomes assessment
Unclear risk No information on blinding of the outcome assessor was provided. Contacting the author was unsuccessful.

Incomplete outcome data
High risk "At baseline, 41 participants were randomly assigned to the treatment group and 26 participants to the control group. Two participants (one from each group) did not complete the data collection at 3 months (T2) and thus they were not included in this analysis; however, they remained in the study. Eighteen participants (26.9%, eleven in treatment group, seven in control group) dropped out of the study. The final sample described here includes 47 participants (treatment = 29, control = 18)." Rationale for judgement: Drop-out rates seem to be equal in both groups, but drop-outs appeared to have less severe disability than those remaining in the study, so data were probably not MCAR, rendering an available case analysis potentially biased. Sensitivity analysis was not conducted. The authors mention a lack of ITT analysis in the limitations section, but it is unclear whether this refers to handling of drop-outs or cross-overs between groups. Contacting the author was unsuccessful.

Selective reporting
Unclear risk This was impossible to judge due to unavailability of a study protocol.
Other biases Low risk No other apparent biases were detected.

Random sequence generation
Low risk "A total of 82 individuals with serious mental illnesses enrolled at a university-based recovery center were randomly assigned to the antistigma photovoice program or to the wait-list, treatment-as-usual control group with the use of a computergenerated program that stratified on gender and racial-ethnic minority status."

Allocation concealment
High risk Allocation concealment was not reported in the study publication. Author contact clarified that participants were randomized based on the time they completed the selfreported baseline assessment and walked to the desk of the research staff to present their baseline packet. Thus, allocation was not concealed.

Blinding of participants and personnel
High risk Blinding of participants and those delivering the treatment was not possible due to the nature of the intervention.

Blinding of outcomes assessment
High risk Blinding of outcomes assessors was not reported in the study publication. Author contact clarified that the follow up assessments were administered by a research assistant working on the project who was aware of the group allocation of the participants.

Incomplete outcome data
Low risk "75 (92%) participants completed the posttest and 78 (95%) completed the three-month follow-up. Intent-to-treat analyses were conducted to test the antistigma photovoice program by using all available data regardless of extent of participation in antistigma photovoice." Rationale for judgement: Authors conducted an available case analysis. However, less than 10% of data were lost and differential attrition was less than 5% (for the 3 month follow up at least), rendering the risk of bias low (see methods section on incomplete outcome data for further information).

Selective reporting
Unclear risk This was impossible to judge due to unavailability of a study protocol.
Other biases Low risk No other apparent biases were detected.

Random sequence generation
Low risk "Following the baseline interview, participants were randomized into either the experimental or control conditions using a computerized number generating system that assigned conditions based on client ID numbers."

Allocation concealment
Unclear risk Information on method of allocation concealment not reported in study publication. The method of allocation concealment remained unclear despite successful author contact.

Blinding of participants and personnel
High risk Blinding of participants and those delivering the treatment was not possible due to the nature of the intervention.

Blinding of outcomes assessment
Low risk The study author was contacted and confirmed that the interviewers were blind when the rating scales were being administered.

Incomplete outcome data
High risk Only data from an "as treated" analysis based on exposure to the intervention were reported in the publication. The author provided additional data from the ITT population for two of the three outcomes included in this review.
Rational for judgement: data from more than 10% (up to 23%) of participants were missing at follow-up. Data were probably not missing at random. Sensitivity analyses were not conducted.

Selective reporting
Unclear risk This was impossible to judge due to unavailability of a study protocol. -All sessions involved elements of the photovoice techniques, including aspects of photojournalism, taking and discussion stigma related images, writing narratives and preparing a public display based on discussions on the appropriate target audience.

Other biases
-Psychoeducation included the following topics: meaning and impact of stigma, prejudice and discrimination and coping strategies for dealing with stigma.
-Psychoeducation and photovoice were integrated and followed a NECT: -20 one-hour structured group session based on four steps: 1) An introductory session that aims to elicit the degree of self-stigma through written exercises; 2) three weeks of psychoeducational including information on the prognosis of mental Treatment as usual: -All participants received standard care, including assessment, medication monitoring, case management, and rehabilitation services. Cointerventions addressing self-Emotional outcomes: Self-stigma (ISMI) Self-esteem (RSES)

Health-related outcomes:
Quality of life (QLS) 3) eight sessions on cognitive restructuring including information on the interaction of thoughts, feelings and behaviour and various exercises on irrational beliefs and how to challenge them and 4) eight sessions with the task of constructing and sharing personally useful stories about oneself in general and in relation to one's illness. stigma were not offered by either of the study sites.
training consisted of an overview of the intervention manual, and included role plays. Two supervisors provided one hour of supervision per group each week. They also assessed fidelity for one session from each intervention phase using a 5-point fidelity scale, where 5 was considered excellent. Fidelity across the two study sites ranged from 4 to 5 (mean 4.4).